When A Pediatric Patient Has Severe Itching On Her Heels

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Key Questions To Consider

1. What essential questions does one still need to ask to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions in your differential?
5. What is the suitable treatment of this condition?

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37
Author(s): 
By William Fishco, DPM, FACFAS

A 4-year-old girl presented to the office with her mother, who was concerned about a skin problem affecting her heels. According to her mother, the patient’s symptoms were present for six months or more. The child’s symptoms included a severe itch that caused constant scratching, pain and cracking of the skin leading to bleeding.
Previous home treatment included the application of various over the counter creams including hydrocortisone, antifungals and hand lotions. These treatments did not help. She had no prior treatment by a physician for this problem.
Her past medical history was remarkable for a benign heart murmur and allergic rhinitis. The patient had been tested by an allergist and is reportedly allergic to trees, grass, weed pollens, cats, dogs, dust mites and molds. She had a very mild milk allergy. The remaining review of systems and history were unremarkable. Her mother stated that her child has reached developmental milestones without any delay.
This patient was a well-developed, 4-year-old Caucasian female. Her vital signs were normal. Vascular, neurologic and orthopedic exams were unremarkable. The dermatologic exam revealed a symmetrical rash on both heels with dry skin, large flaking scales and deep fissures with evidence of prior bleeding. She also had small skin fissures on the dorsal skin folds of her fingers at the PIP joints. The child had no other rashes.

A Guide To The Differential Diagnosis
Xerosis of skin is a very common skin disorder, especially in older people. Although one may see xerosis in children, its frequency increases with age. Xerosis, which is also known as asteototic eczema, occurs more frequently in winter months and/or in drier climates.
Clinically, the presentation involves dry looking skin, possible fissures and scaling of skin. Other areas of the body such as the lower legs and hands can be affected as well. Certain systemic diseases such as diabetes and hypothyroidism can contribute to xerosis as they can affect vasomotor function to the skin. Xerosis is not caused by a lack of oils in the skin but rather a lack of water. Known irritants would include using salts in the bath, hot water, frequent bathing and harsh soaps. Treatment involves restoring moisture in the skin by drinking plenty of water and using moisturizing creams immediately after the bath or shower.
By definition, eczema is the clinical appearance of an inflammatory skin eruption. Oftentimes, clinicians use dermatitis interchangeably. Some clinicians use the term dermatitis for an acute presentation and eczema as a chronic condition. Atopy is associated with asthma, allergic rhinitis, eczema, food allergies, urticaria and elevated IgE levels.

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